Breast is the worstest x5?

[medgator]

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Not to derail from breast, but I had a real oh f*** moment recently. Evicore tried to deny neoadjuvant CRT for a low rectal cancer because in their algorithm, radiation is not indicated for rectal cancer. No note from surgery explicitly recommending radiation = no monies. Because of a single non-inferiority trial.

And don’t expect randomized evidence to save us..These same a** clowns won’t approve 35 fractions for intact prostate a la FLAME and will say with a straight face they need a confirmatory trial to change their algorithm and approve more than 28 fractions. Even though a single non-inferiority trial will suffice to stop approving radiation for another disease site.

Took them several years to routinely approve IMRT in stage 3 lung after the 0618 dosimetric study came out. So obvious these pts should have been getting it all along without stupid 3D plan comparisons

Probably because we have such a weak lobby everywhere compared to med onc even though we are a drop in the bucket, cost wise

 

[TheWallnerus]

Not to derail from breast, but I had a real oh f*** moment recently. Evicore tried to deny neoadjuvant CRT for a low rectal cancer because in their algorithm, radiation is not indicated for rectal cancer. No note from surgery explicitly recommending radiation = no monies. Because of a single non-inferiority trial.

And don’t expect randomized evidence to save us..These same a** clowns won’t approve 35 fractions for intact prostate a la FLAME and will say with a straight face they need a confirmatory trial to change their algorithm and approve more than 28 fractions. Even though a single non-inferiority trial will suffice to stop approving radiation for another disease site.

I think you got fake peer to peered?

 

[ramsesthenice]

I think you got fake peer to peered?

View attachment 411506

I sure hope so. They definitely attempt to deny things that are SOC in (I assume) hopes the denial can stick if you just refuse to show up. I havnt had this out east, but in the Midwest, I would still occasionally get a P2P request for IMRT for definitive prostate. I never had to say a thing aside from confirming the case number and patient DOB. The reviewer would run through the case and then approve in the same breath. I don’t claim to be an Evicore expert by any means but have heard of “the dial” in vague discussions. Not sure if this was turning the dial or not. But an epic waist of time it was regardless..

 

[A_DeMichele]

always worth looking at the actual Evicore guidelines before picking the phone IMO...